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Organizational factors associated with the effective implementation and translation of a primary care based behavioral program to improve blood pressure control: The HTN-IMPROVE study
Shaw R, Kaufman M, Bosworth HB, Weiner BJ, Lee SD, Kravetz JD, Rakely SM, Roumie CL, Bowen ME, Del Monte PS, Oddone EZ, Zullig LL, Jackson GL. Organizational factors associated with the effective implementation and translation of a primary care based behavioral program to improve blood pressure control: The HTN-IMPROVE study. Poster session presented at: AcademyHealth Annual Research Meeting; 2013 Jun 23; Baltimore, MD.
Research Objective: We sought to implement an evidence-based nurse-delivered self-management phone intervention to facilitate hypertension management within a large complex health system. The Hypertension Telemedicine Nurse Implementation Project for Veterans (HTN-IMPROVE) was deployed in primary care practices in 3 Veterans Affairs Medical Centers (VAMCs). Guided by the Weiner Organizational Theory of Implementation Effectiveness, a model of the determinants of effective innovation implementation in organizations, we sought to answer the following research questions: 1) What is the level of organizational readiness to implement the intervention? 2) What are the specific facilitators, barriers, and contextual factors that may affect organizational readiness to change?
Study Design: Facilities agreed to enroll 500 participants over a 1 year period with at least 0.5 full time equivalent employees of nursing time to execute the program. A priori semi-structure interviews were conducted with 27 stakeholders including nurses, physicians, administrators, and information technology professionals between 2010 and 2011. Through transcript review, researchers iteratively identified facilitators and barriers of organizational readiness to change (ORC) and intervention implementation.
Population Studied: 27 primary care stakeholders from 3 geographically diverse VAMCs.
Principal Findings: Key ORC facilitators included: Stakeholder buy-in; improving hypertension is a key performance metric and benefits of HTN-IMPROVE are recognized. Positive organizational characteristics likely to impact ORC include: 1) Situational factors: other similar programs (e.g. telehealth) that support buy-in, adequate staff, and alignment with existing clinic workflow and climate; 2) change valence (perceived value to organization's members): improvement in patient outcomes, is positive for the professional nurse role, and is evidence-based; 3) task demands: general understanding of the program to be implemented; 4) resource availability: office space, IT infrastructure and support, and existing equipment will be used. The primary ORC barrier was unclear long-term commitment of nursing. Negative organizational characteristics likely to impact ORC include: 1) situational factors: added workload, competition with existing clinical programs, length of implementation, and limited time available by nursing staff; 2) change valence: buy-in is only temporary until evidence shows improved patient outcomes; 3) task demands: contacting patients may be difficult, and the logistics of integration into existing workflow could be a challenge; 4) resource availability: inadequate staffing.
Conclusions: The model of organizational change identified key facilitators and barriers of organizational readiness to change and successful implementation of HTN-IMPROVE. Results show that ORC and readiness to implement the program is primarily positive as indicated by the perceived value of the program. However, the primary negative factors include unclear nursing buy-in, and as perceived by key stakeholders, resource availability.
Implications for Policy, Delivery or Practice: There is a significant gap between discovery and delivery of evidence-based hypertension interventions. This study allows us to understand the needs and challenges of intervention implementation. Furthermore, examination of organizational facilitators and barriers to implementation of evidence-based interventions may inform dissemination in other chronic diseases. This project may have a substantial impact on hypertension management by helping VA and other health systems accelerate the translation of evidence-based medicine and reductions in health disparities.